Benefits for Plan Year 2014

The following benefits are available at Scott & White Health Plan designated facilities when medical care is necessary and provided, authorized, ordered, or arranged by your Group Physician.

Summary of HMO Benefits for Plan Year 20141,10

Benefit Description

Member's Cost Share
PY2014

Plan year out-of-pocket coinsurance maximum (per person)

$2,000

Plan year out-of-pocket copayment maximum (per person)

None

Lifetime maximum 

None 

Physicians and Lab Services

*Physician office visit Primary Care Physician (if applicable)

$25

*Specialist office visit

$40

*Routine preventive care- Once per calendar year or as directed by the primary care physician (if applicable)

  • Children and Well Baby periodic exams
  • Well Woman exam (to include Cervical Cancer Screening)
  • Men's Health Exam

No Charge

*Diagnostic x-rays, mammography, and lab tests

20%

High Tech Radiology (CT Scan, MRI, and Nuclear Medicine) Outpatient testing only

$100 copayment plus 20%

*Immunizations - For children and adults

No charge

*Vision, speech, and hearing screenings - For all enrolled Participants

20% without office visit,
$40 plus 20% with office visit

*Colorectal Cancer Screening - (zero cost sharing for certain preventive services under the Affordable Care Act)

No charge

*Exam for Detection and Prevention of Osteoporosis - (zero cost sharing for certain preventive services under the Affordable Care Act)

No charge

*Cervical Cancer Screening - (zero cost sharing for certain preventive services under the Affordable Care Act)

No charge

*Tubal Ligation – (zero cost sharing for certain preventive services under the Affordable Care Act) No charge

Speech and hearing testing - For all enrolled Participants

20% without office visit,
$40 plus 20% with office visit

Speech therapy and rehabilitative therapy, including physical and occupational therapy - Covered as any other illness and not subject to any maximum

20% without office visit,
$40 plus 20% with office visit

Allergy testing

20%

Allergy serum

20%

Allergy serum administration - When allergy shot is administered without an office visit

20%

*Routine eye exam - One per plan year2

$40

Office surgery and procedures (all office surgeries, excluding vasectomies and tubal ligations)

20%

*Maternity care (physician services only)- Pre- and post-natal care, and network obstetrician delivery charges (including delivery by C-section) - see "Hospital Services" for inpatient charges (Does not include complications of pregnancy.)

Pre-natal office visit and obstetrician delivery: No Charge

Post-natal office visit: $25 copayment primary care physician, $40 copayment specialist

Family planning

$40

Vasectomy

20%

Infertility benefits3

50%

Hospital Services9

 

Inpatient hospital - Semi-private room and board or intensive care units; other inpatient charges, including medically necessary surgical procedures.  Includes orthognathic surgery.  Personal items not covered are as follows: Guest trays, cots, telephone, maternity kits, and paternity kits.

$150 per day copayment per admission, 5 day max.
$2,250 max. per person per year plus 20%

Outpatient day surgery

$100 copayment plus 20%

Blood and blood products - Inpatient and outpatient

20%

Outpatient facilities, including pre-admission testing and/or treatment room

20%

Emergency care - In-area and out-of-area covered at listed copayment. If hospitalized, copayment is applied to hospital confinement.

$150 copayment plus 20%

Urgent care- Includes physician's after-hours care or at an urgent care facility

$50 copayment plus 20%

Extended Care Services (Based on medical necessity)

 

Skilled nursing facility (based on medical necessity) - Covered up to 60 days per plan year

20%

Hospice care - Inpatient and outpatient (based on medical necessity)

20%

Home health

20%

Private duty nursing

20%

Other Medical Services

 

Hearing aids (repairs not covered)

Plan pays $500 per ear every 3 years

Hearing aid batteries - Not subject to any maximum amounts

20%

Dental4 - Restoration and correction of damage caused by external violent accidental injury to healthy, natural teeth, occurring while covered under the plan for services provided within 24 months of the date of the accident. Certain oral surgeries are covered.

20%

Durable Medical Equipment5, 6 - Includes medically necessary purchase and/or rental. Benefits for rental are limited to, and will not exceed, the purchase price of the equipment. (Repairs are covered if not due to neglect or abuse.)
This benefit also includes diabetic supplies other than insulin, diabetic oral agent(s), and syringes as specified in Section 1358.051(2), Tex. Ins. Code.

20%

Prostheses - Artificial devices, surgical or non-surgical, which replace body parts, including arms, legs, eyes and cochlear implants are covered.  Replacements and repairs are covered as required by medical necessity. Prosthetic devices, orthotic devices, and professional services related to the fitting and use of these devices are included, if services are pre-authorized and provided by a contracted provider. 20%

Organ Transplants - Covered as any other illness for kidney, cornea, liver, heart, heart-lung, lung, pancreatic-kidney, bone marrow, and other organ transplants that the HMO determines to be not experimental and/or not investigational according to current medical plan guidelines. Donor expenses are covered. Artificial organs (e.g. heart) not covered.

$150 per day copayment per admission, 5 day max.
$2250 max. per person per year plus 20%

Ambulance - Professional local ground or air ambulance transportation services to the nearest hospital, appropriately equipped and staffed for the treatment of the participant's condition

20%

Behavioral Health Care Benefits

 

Inpatient mental health

$150 per day copayment per admission, 5 day max.
$2250 max. per person per year plus 20%

Inpatient serious mental illness - Covered as any other illness7

$150 per day copayment per admission, 5 day max.
$2250 max. per person per year plus 20%

Inpatient chemical dependency - Covered as any other illness (based on medical necessity)

$150 per day copayment per admission, 5 day max.
$2250 max. per person per year plus 20%

Outpatient mental health

$40

Outpatient serious mental illness - Covered as any other illness7

$40

Outpatient chemical dependency - Same as any other illness and not subject to any maximums

$40

Prescription Drugs8

 

Plan Year Deductible

$50

If a brand-name medication is dispensed when a generic is available, member will be responsible for the generic copayment plus the cost difference between the generic and the brand-name medication.

 

Participating Retail Pharmacy - Tier 1, Tier 2, & Tier 3

 

Up to 30-day supply per prescription or refill of Non-Maintenance medication

$15/$35/$60

Up to a 30-day supply per prescription or refill of Maintenance medication

$20/$45/$75

Infertility drugs

50%

Up to a 30-day supply of insulin for one copayment

$15/$35/$60

Up to a 30-day supply of each diabetic oral agent for one copayment

$15/$35/$60

The supply of necessary disposable syringes for the insulin supply for one copayment

$35

Diabetic supplies other than insulin, diabetic oral agent(s), and syringes as specified in Section 1358.051(2), Tex. Ins. Code up to a 30-day supply.

20%

Mail Order Pharmacy - Tier 1, Tier 2, & Tier 3

 

Up to a 90-day supply per prescription or refill for one mail order copayment

$45/$105/$180

Infertility drugs

50%

Up to a 90-day supply of insulin for one mail order copayment

$45/$105/$180

Up to a 90-day supply of each diabetic oral agent for one mail order copayment

$45/$105/$180

The supply of necessary disposable syringes for the insulin supply for one mail order copayment

$105

Diabetic supplies other than insulin, diabetic oral agent(s), and syringes as specified in Section 1358.051(2), Tex. Ins. Code up to a 90-day supply.

20%

Pre-existing conditions are covered as of 12:01 a.m. September 1, 2012 and lifetime benefit maximums are unlimited. 

*Under the Affordable Care Act, certain preventive health services are paid at 100% (i.e., at no cost to the member) dependent upon physician billing and diagnosis. In some cases, you will be responsible for payment of some services.

Footnotes:

1. This Summary of HMO Benefits reflects the current benefit plan structure and is subject to change as required by state and federal laws, rules and regulations or if ERS deems it to be in the best interest of ERS, the GBP, its Participants, and the state of Texas.  All state mandated services shall be provided for in the HMO’s Evidence of Coverage whether included in or omitted from this Summary of Benefits.  The Summary of the HMO Benefits itemizes the services required by Chapter 1551, TIC, generally, by the TIC and by the rules of the TDI.  The Summary of the HMO Benefits is not intended to identify all services required by the TIC, TDI; however, the following benefits should be listed:

a.   Well-child care from birth per TIC section 1271.154;
b.   Screening test for hearing loss for newborns per TIC section 1367.103;
c.   Tests for detection of prostate cancer per TIC section 1362.003;
d.   Tests for detection of colorectal cancer per TIC section 1363.003;
e.   Coverage for hospital stays following performance of a mastectomy and certain related procedures per TIC section 1357.054;
f.    Coverage for reconstructive surgery after mastectomy per TIC section 1357.004;
g.   Benefits for detection and prevention of osteoporosis per TIC section 1361.003;
h.   Coverage for craniofacial abnormalities per TIC section 1367.151-153;
i.    Telemedicine per TIC section 1455.004;
j.    Anesthesia for dental procedures in a hospital setting per TIC Chapter 1360;
k.    Coverage for certain benefits related to brain injury per TIC Chapter 1352;
l.    Coverage for prescription contraceptive drugs and devices and related services per TIC section 1369.104;
m.  Coverage for inpatient stay following childbirth per TIC section 1366.055;
n.   Coverage for special dietary formulas for individuals with Phenylketonuria (PKU) or other heritable diseases per TIC section 1359.003;
o.   Coverage for certain amino acid-based elemental formulas per TIC section 1377.051;
p.   Coverage for off-label drug use per TIC Chapter 1369;
q.   Coverage for fibrocystic breast conditions per TIC section 544.201-204;
r.    Eligibility for benefits for Alzheimer’s disease per TIC Chapter 1354;
s.   Coverage for cervical cancer per TIC Chapter 1370;
t.    Coverage for certain tests for early detection of cardiovascular disease per TIC section 1376.003;
u.   Coverage for routine patient care costs for enrollees participating in certain clinical trials per TIC section 1379.051; and
v.   Coverage for autism spectrum disorder from date of diagnosis until the enrollee completes nine years of age per TIC section 1355.015.

  1. Routine eye exam means an eye exam by a Doctor of Ophthalmology or a Doctor of Optometry which, when within the scope of their license, includes such services as:
  • External examination of the eye and its structure;
  • Determination of refractive status; and
  • Glaucoma screening test.

It does not include a contact lens exam, prescriptions or fittings of contact lenses or eyeglasses, and the cost of the contact lenses or eyeglasses.

3. Infertility Benefits do not include sterilization reversal, transsexual surgery, gender reassignment, intra-fallopian transfer and related services, artificial insemination, or in-vitro fertilization.  Also excluded from coverage are any services or supplies used in any procedures performed in preparation for or immediately after any of the above-referenced excluded procedures.  Pharmaceuticals are covered at 50% copayment.

4. Certain oral surgeries mean maxillofacial surgical procedures limited to:

  • Excision of neoplasm, including benign, malignant and premalignant lesions, tumors, and nonodontogenic cysts.
  • Incision and drainage of cellulitis.
  • Surgical procedures involving accessory sinuses, salivary glands and ducts.
  • Coverage for temporomandibular joint (“TMJ”) shall be in compliance with Chapter 1360, TIC.  Excludes oral appliances and devices used to treat TMJ pain disorders or dysfunction of the joint and related structures, such as the jaw, jaw muscles, and nerves.

5. The diabetes benefit is as listed in Section 1358.051 of the TIC and includes benefits for diabetic equipment, diabetes supplies, and diabetes self-management training programs as follows:

Diabetic equipment: (20% copayment)
a.   Blood glucose monitors, including monitors designed to be used by blind individuals.
b.   Insulin pumps and associated appurtenances.
c.   Insulin infusion devices.
d.   Podiatric appliances for the prevention of complications associated with diabetes.

Diabetic supplies:
a.   Insulin and insulin analogs (covered under pharmacy benefit).
b.   Syringes (covered under pharmacy benefit at the Tier 2 copayment).
c.   Prescriptive and nonprescriptive oral agents for controlling blood sugar levels (covered under pharmacy benefit).
d.   Glucagon emergency kits (covered under pharmacy benefit).
e.   Test strips for blood glucose monitors (20% copayment).
f.    Visual reading and urine test strips (20% copayment).
g.   Lancets and lancet devices (20% copayment).
h.   Injection aids (20% copayment).
i.    Alcohol wipes (20% copayment).

Diabetic self-management training programs: (same as office visit copayment)
a.   Training provided after the initial diagnosis of diabetes in the care and management of that condition, including nutritional counseling and proper use of diabetes equipment and supplies.
b.   Additional training is provided after a diagnosed significant change in the member’s symptoms or condition that requires changes in the self-management regime.
c.   The Food and Drug Administration approves periodic or episodic continuing education training as warranted by the development of new techniques and treatments for the treatment of diabetes.

6. ERS defines orthotics as pertaining to the feet; therefore, services or supplies for routine foot care, insoles, or shoe inserts of any type are not covered, except when prescribed for a diagnosis of or related to the treatment of diabetes or circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency.  Orthotic devices, and the professional services relating to the fitting and use of those devices, are covered if the services are pre-authorized and provided by a contracted provider.

7. Restrictions on mental health benefits are not applicable to expenses incurred for the treatment of “serious mental illness” as defined in Section 1355.001, TIC.  At a minimum, coverage for autism spectrum disorder must be provided from the date of diagnosis until the enrollee completes nine years of age as described in Section 1355.015, TIC.

8. Pharmacy Benefits: ERS allows the use of a formulary provided it offers a broad spectrum of high quality drug therapies.  Vitamins are not covered except those that require a prescription by law and have no non-prescription equivalent.

9. Weight reduction programs, services, supplies, surgeries, or gym memberships are not covered, even if the Participant has medical conditions that might be helped by weight loss, or even if prescribed by a physician.

10. All Applicable Copayment and Deductible Resets

10.a. Break in Coverage.  The prescription drug deductible and the inpatient out-of-pocket maximum per person per plan year should be reset for a Participant designated as a new hire.  This would include an employee who left state or higher education employment and experienced a break in health insurance coverage.  This Participant would be considered a new employee and the prescription deductible and the inpatient out-of-pocket maximum should be calculated the same as for a new employee.

10.b. COBRA/Dependent Coverage.  Participants under COBRA and dependents who were previously covered but are now directly insured under the GBP shall not be requested to satisfy a new prescription deductible and inpatient out-of-pocket maximums as soon as their coverage becomes effective as a directly insured GBP Participant.